'Contagion' portrays extreme but not impossible scenario

Sep 9, 2011 (CIDRAP News) – In the film "Contagion," opening in theaters today, a respiratory virus from Malaysia makes its way from bats to humans, spreading quickly around the world and killing a high proportion of those infected. It's clearly an extreme scenario, but not an impossible one, say experts who have seen the movie.

The general verdict of infectious-disease and epidemiology experts interviewed by CIDRAP News is that the film tells an engaging and suspenseful story without asking viewers to swallow too many scientific and public-health whoppers—though the experts do have some reservations.

"It's one of the most accurate movies I have seen on infectious disease outbreaks of any type," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

"It did depict what would be an extremely rare possibility of a worst-case scenario," he said. "Audiences will look at this and say, 'Could it happen?' Certainly it could happen, but it's extremely unlikely to happen."

Striving for realismThe filmmakers enlisted experts in a resolute effort to make the story as realistic as possible, according to media reports. A major consultant was Dr. Ian Lipkin, director of the Center for Infection and Immunology at Columbia University's Mailman School of Public Health, who began working with the filmmakers in 2008, according to a recent online report in Scientific American.

The producers also sought technical advice from the Centers for Disease Control and Prevention, according to CDC spokesman Tom Skinner in Atlanta. "A number of cast members came to CDC," he told CIDRAP News. "The director, [Steven] Soderbergh, spent a number of days down here talking to staff and learning how CDC goes about investigating. They did their homework in regards to researching just how public health mobilizes during an outbreak."

The push for scientific verisimilitude included recruiting Craig Street, a bioinformatics analyst at Columbia, to design the fictional virus, according to the Scientific American report. He created a model of a virus that combined elements of a nipah virus from bats and a rubulavirus from pigs.

The efforts at scientific accuracy show, according to those who have seen the final results. And where the film strays from realism, experts are willing to make some allowances in recognition of the need to tell a good story.

"The scientific aspects of how it unfolded were excellent, a testament to the fact that Ian Lipkin was heavily involved," said Fauci. He called the film "entertaining, in the sense of very dramatic, tense, exciting, somewhat scary to people who don't understand these things very well."

Dr. Ruth Lynfield, state epidemiologist in Minnesota, where some of the depicted events take place, commented, "I thought that it was a very interesting movie and from a story perspective very engaging. I think it does raise a concern that is a big concern for public health folks, which is an emerging virus that is very communicable and has a very high case-fatality rate" (CFR).

Michael T. Osterholm, PhD, MPH, director of the University of Minnesota Center for Infectious Disease Research and Policy, publisher of CIDRAP News, agreed that the admittedly extreme scenario in the movie is possible.

"I'd say the potential for such an outbreak to actually occur is real," he said. "There was nothing hyped about the potential for an agent like this to actually develop."

Distorted public health responseBut both he and Lynfield had reservations about the way the public health response to the disease is portrayed.

"The movie really portrayed it as being some midlevel people at CDC and Homeland Security pretty much running everything, with a limited number of people at the WHO [World Health Organization]," Osterholm said. "In reality this would be a cast of thousands, including the president's office."

For artistic reasons, "they had to focus on several characters, as if they were a large part of the response, which is not true," he added.

Lynfield commented, "I think a lot more people would be involved in the response than was depicted . . . from the federal to the state to the local level. I think that CDC would be involved in making recommendations about nonpharmaceutical approaches to prevention and control and not solely working on the investigation in Minnesota and on characterizing the virus and developing the vaccine."

She added that, in line with pandemic preparedness planning, an epidemic like the one portrayed would invoke much work on nonpharmaceutical interventions and other responses at the state and local levels and would inspire much more communication with the public and clinicians.

Speedy vaccine developmentOne scientific aspect of the film that strains credulity, the experts say, is how quickly a vaccine against the new virus is developed.

"One issue that concerns me is that by day 130 [from identification of the virus] we're beginning to distribute a vaccine, which would never happen in a realistic way," said Osterholm. He said the vaccine is an intranasal one, suggesting that it's a live attenuated virus, which would probably take even longer to develop than an inactivated injectable vaccine.

Fauci said the film shows the vaccine being developed and distributed within 144 days, which he called "slightly unrealistic but not egregiously so."

An additional flaw, he said, is how the vaccine is shown being initially tested. A CDC staff member inoculates herself with the vaccine and then has intentional contact with her sick father, but does not get sick. "On the basis of that they started producing the vaccine," Fauci said. "The fact that they used a vaccine trial with an 'n' of 1 was unrealistic."

Lynfield mentioned a couple of other concerns, but not major ones. The fictional virus jumps from bats to swine and from swine to humans, a process that happens quickly in the film. "That timeline is kind of rapidly pushed," she said. "But that I think really was meant to show that many of the emerging infections have a zoonotic origin."

Also, she said the film omits the fact that simple supportive care can help some patients in a pandemic.

The movie also portrays a certain level of social disruption and chaos, a dimension that may actually be underplayed, in Osterholm's view. "I think it could actually be worse, because of global products running out," he said. For example, he said a severe pandemic could cripple the coal industry, leading to electric power outages.

An anti-science schemerOne part of the story that drew particular praise from Fauci and Lynfield is the depiction of a schemer who capitalizes on anti-science sentiments to push a questionable product. Fauci said Jude Law plays an unscrupulous blogger who tries to sell a homeopathic herb as a cure for the virus.

"It created a lot of confusion and irrational behavior. It does point out the damage that unscrupulous bloggers and demagogues could cause in a serious situation," he said.

Despite their concerns and reservations, the experts say the film is valuable for focusing attention on the threat of emerging diseases and the need for a strong public health system.

"I think it'll surely create a lot of discussion, which is good," said Osterholm.

"People have to remember it's a movie, not a documentary," said Lynfield. "The movie does put a spotlight on the issue of emerging infections and the importance of having a strong public health infrastructure and having good scientists who are able to characterize viruses and develop a vaccine."